While technologic advances in imaging techniques such as US, CT, and MRI have contributed tremendously to patient care, expenditures related to their use have increased rapidly and significant practice pattern variation exists in imaging utilization. Substantial numbers of imaging examinations may be unnecessary or redundant, exposing patients to excess radiation and the medical system to significant waste. Growing amounts of comparative effectiveness research (CER)-informed evidence exists for imaging, but rapid adoption is required to realize its benefits. This study will implement and assess impact of a real-time clinical decision support system (DSS) embedded in computerized physician order entry (CPOE) as a vehicle for increasing the pace of dissemination and adoption of imaging-related CER findings. The specific aims are to: Aim 1: Develop educational content to be delivered as automated imaging DSS and related accountability tools for three CER-informed evidence based guidelines (EBGs). Aim 2: Deploy the EBG-based DSS, relevant prior examination DSS, and accountability tools in two large healthcare institutions, one with well-established imaging clinical decision support systems and one with HIT infrastructure without current imaging DSS. Aim 3: Assess the outcome of DSS implementation including meaningful use of imaging CPOE and adoption of DSS, the efficacy of the system in promoting evidence-based practice, and the appropriateness of image ordering compared to CER-informed findings. Aim 4: Assess the extent to which the addition of accountability tools improves adoption of CER into practice. The factual evidence presented in the guidelines will be used to generate a computable representation that is integrated into the image ordering workflow at two pilot site health systems. Data about imaging ordering behavior (including canceled, expired and changed orders) will be collected in a central imaging repository. The primary outcome measure will be the extent to which image orders adhere to the recommendations in the evidence-based guidelines, and the extent to which users accept or ignore the decision support advice or change to a different imaging modality. PUBLIC HEALTH RELEVANCE: The growth in the use of imaging services has contributed tremendously to patient care, but has lead to concerns about potentially unnecessary or redundant imaging examinations, exposing patients to unnecessary radiation and the medical system to significant waste. This project will use healthcare information technology tools (HIT) such as decision support to help clinicians make evidence-based decisions when requesting imaging studies to improve quality and reduce waste. If effective, this project will serve as a model for increasing the pace of adoption of imaging-related comparative effectiveness research findings to improve the practice of medicine.